1

AIRCRAFT ACCIDENT INVESTIGATION BUREAU

FINAL INVESTIGATION REPORT ON ACCIDENT

TO BEECH-CRAFT KING AIR B200 AIRCRAFT VT-HRA

AT CHANDIGARH AIRPORT

ON 27th MARCH 2014

MINISTRY OF CIVIL AVIATION

GOVERNMENT OF INDIA

NEW DELHI (INDIA)

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AAIB (India) Report No. : 2014-ACC-0

File No. AV.15013/0 /2014-AAIB

Published on:

In accordance with Annex 13 to the International Civil Aviation

Organisation Convention and the Aircraft (Investigation of

Accidents & incidents) Rules 2012, the sole purpose of this

investigation is to prevent aviation accidents. It is not the purpose

of the investigation and the associated investigation report to

apportion blame or liability.

Safety recommendation shall in no case create a presumption of

blame or liability for an occurrence.

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FINAL REPORT ON

ACCIDENT TO BEECH-CRAFT KING AIR B200 AIRCRAFT VT-HRA

AT CHANDIGARH AIRPORT ON 27th MARCH 2014

1. Aircraft

Type : BEECH-CRAFT KING AIR

Model : B 200

Nationality : INDIAN

Registration : VT-HRA

2. Owner and Operator : GOVT. OF HARYANA

3. Date of Accident : 27.03.2014

4. Time (IST) : 11: 39 hrs.

5. Last point of Departure : Chandigarh

6. Point of intended landing : Safdarjung (Delhi)

7. Geographical location of : 300 40‟ 28”N / 760 47‟ 21”E

Accident site (Lat. Long) :

8. Type of operation : Passenger

9. Phase of operation : Take off

10. Commander’s License : ATPL

11. Extent of Injury : Nil

12. First Officer License : CPL

13. Extent of Injury : Nil

14. Damage to aircraft : Substantial

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I N D E X

SYNOPSIS 6

1.0 FACTUAL INFORMATION 7

1.1 History of the flight 7

1.2 Injuries to persons 8

1.3 Damage to aircraft 9

1.4 Other damage 10

1.5 Personnel information 10

1.5.1 Pilot – in – Command 10

1.5.2 Co-Pilot 10

1.6 Aircraft information 11

1.7 Meteorological information 16

1.8 Aids to navigation 16

1.9 Communications 17

1.10 Aerodrome information 17

1.11 Flight recorders 17

1.12 Wreckage and impact information 17

1.13 Medical and pathological Information 20

1.14 Fire 20

1.15 Survival aspects 20

1.16 Tests and research 20

1.17 Organizational and management information 20

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1.18 Additional information: 21

1.19 Useful or effective investigation techniques 23

2.0 ANALYSIS 24

2.1 Serviceability of the aircraft 24

2.2 Crew Qualification 26

2.3 Weather 27

2.4 Circumstances leading to the accident 27

3.0 CONCLUSIONS 29

3.1 Findings 29

3.2 Probable cause of the Incident 30

4.0 SAFETY RECOMMENDATIONS 31

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SYNOPSIS :

Beech Craft King Air B200 aircraft VT-HRA was involved in an accident at Chandigarh

airport on 27th March 2014. Within 3-4 seconds of getting airborne the aircraft impacted

the ground in left bank attitude. The initial impact was on pucca (tar road) and the left

wing took the impact loads with lower metallic surface rubbing and screeching on

ground.

The aircraft was substantially damaged. There was no fire barring burning of small

patch of grass due coming in contact with the hot surfaces and oil. There was no injury

to any of the occupants. The accident occurred in day light conditions.

Government of India vide notification no. AV.15018/12/2014-VE ordered the

investigation of the accident by a Committee of Inquiry. The intimation of the accident

was provided to ICAO, TSB Canada and NTSB USA as per the requirements of ICAO

Annexure 13.

The investigation of the accident was carried out by taking into account all the

evidences on record. The accident occurred due to stalling of left wing of the

aircraft at a very low height. The contributory factors were:

Crew was not able to effectively put off the yaw damp so as to release

the rudder stiffness as per the emergency checklist.

Checklist not being carried out by the crew members.

Not putting off the Rudder Boost.

Speeds call outs not made by co-pilot.

Not abandoning the take-off at lower speed (before V1).

Failure of CRM in the cockpit in case of emergency.

Early rotation and haste to take-off.

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1. Factual Information 1.1 History of flight

On 25.03.2014, the operator received the travel programme for 27.3.2014, of

Hon‟ble Governor of Haryana from Chandigarh to Delhi. On 26.3.2014, the

operations department took the flight clearances and filed the passenger

manifest with the ATC and other concerned agencies.

The flight plan was filed by a CPL holder, who is working as flight dispatcher

with the Government of Haryana. The departure on 27.3.2014 was fixed at

1130 hrs. The cockpit crew reported at 1045 hrs for the flight. Pre flight

medical examination including the breath analyzer test was carried out at

1100 hrs. The breath analyzer test for both the cockpit crew members was

negative. Pre flight briefing among the crew members was carried out by

using the documents prepared by the flight dispatcher. The aircraft was taxied

under its own power from Haryana Government Hangar to bay no. D-2 in

front of ATC building. No abnormality was observed or reported on the aircraft

during this taxiing. The engines were shut down for passenger embarkation.

As per the passenger manifest, in addition to the pilot and co-pilot there were

8 passengers. The baggage on board was approx. 50 lbs. There was 2100

lbs. of fuel on board. After boarding of the passengers, the aircraft engines

were started at 1130 hrs. The aircraft was cleared for departure abeam „D‟

link. The aircraft was taxied out via taxiway „D‟. After ATC departure

clearance the aircraft was lined up for take-off. On clearance from ATC the

take off roll was initiated and all the parameters were found normal. As per

the pilot just before getting airborne some stiffness was found in rudder

control as is felt in yaw damper engagement. The aircraft then pulled slightly

to the left which as per the Commander was controllable. As per the pilot, the

rotation was initiated at 98 knots.

As per the DATCO the aircraft had lifted upto 10-15 feet AGL. The

Commander has stated that after lift-off, immediately the left rudder got

locked in forward position resulting in the aircraft yawing and rolling to left.

The pilots tried to control it with right bank but the aircraft could not be

controlled. Within 3-4 seconds of getting airborne the aircraft impacted the

ground in left bank attitude. The initial impact was on pucca (tar road) and the

wing has taken the first impact loads with lower surface metallic surface

rubbing and screeching on ground.

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After the aircraft came to final halt, the co-pilot opened the door and

evacuation was carried out. There was no injury to any of the occupants. The

engine conditions lever could not be brought back as these were stuck. The

throttle and pitch levers were retarded. The fuel shut off valves were closed.

Battery and avionics were put off. Friction lock nuts were found loose.

As per the Commander, after ensuring safety of passengers he had gone to

cockpit to confirm that all switches were „off‟. At that time he has loosened the

friction lock nuts to bring back the condition lever and throttle lever. However

even after loosening the nut it was not possible to bring back these levers.

Fire fighting vehicles were activated by pressing crash bell and primary alarm.

Hand held RT set was used to announce the crash. RCFF vehicles

proceeded to the site via runway and reported all the 10 personnel are safe

and out of the disabled aircraft. Water and complementary agents (foam and

dry chemical powder) were used. After fire was extinguished, the Fire

Fighting vehicles reported back at crash bay except one CFT which was held

at crash site under instruction of COO.

The aircraft was substantially damaged. There was no fire barring burning of

small patch of grass due coming in contact with the hot surfaces and oil.

There was no injury to any of the occupants. The accident occurred in day

light conditions.

1.2 Injuries to persons

INJURIES CREW PASSENGERS OTHERS

FATAL Nil Nil Nil

SERIOUS Nil Nil Nil

NONE 2 8

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1.3 Damage to aircraft

The aircraft was substantially damaged particularly the wings, landing gear,

both the engines bottom surfaces. The major damages to the aircraft are as

follows:

On left hand side the out board wing section was damaged and ripped off at

6‟ outboard from the wing attachment point and again bent at around 13‟ from

the wing attachment point). Wing tip suffered substantial damage. Aileron was

found damaged and broken due to impact. LH Engine ripped off from the four

engine mounts with all pipelines broken from firewall. Friction lock nut was

found loose. Condition lever position was found toward low idle with control

cable intact. Power lever cable found broken from the eye end. LH Landing

gear found extended (11”) and locked. No visible damage on Landing gear.

Dorsal fin ripped off from the mounting and found with the Vertical stabilizer.

On right hand side dents were observed around the aft pressure bulkhead.

Outboard tip of Inboard flap and inboard tip of outboard flap were found

damaged. Wing leading edge section ripped off from the forward piano hinge.

Wing tip suffered extensive damage. RH MLG broke from structural mounting.

Lower drag brace found broken. RH Landing gear doors were found

completely damaged. RH Engine found ripped off from all the four mounting

points. Condition lever found at high idle and cable found bent and intact.

Power lever found at low power and cable found intact.

In the nose section, Nose landing gear broke from mounting. Nose section

completely dislodged from the fuselage. Radome found dislodged and

completely damaged. Inner cylinder of nose landing gear shock absorber

found dislodged of the landing gear along with nose wheel assembly. Shimmy

damper found broken from the piston. Nose landing gear Steering linkage

found completely damaged. Nose landing gear torque link separated from the

scissor linkage point.

LH engine Propeller assembly was found near the wingtip of RH Wing. One

blade of LH Propeller ripped off at around 17” from the root. Extensive

rubbing marks of all LH Propeller blade tips. All blades of LH Propeller found

bent and completely damaged. LH and RH Propeller Spinner assembly found

completely damaged. All blades of RH Propeller found rubbed at the tip and

completely damaged.

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1.4 Other damage

Nil

1.5 Personnel information

1.5.1 Pilot – in – Command

Age : 58 years

License : ATPL

Date of Issue : 24.09.1992

Validity : Valid

Category : Multi Engine land

Endorsements as PIC Endorsement as PIC : B 737, B-200, Open rating

Date of Medical Examination : 11/03/2014

Med. Exam valid upto : 10/09/2014

FRTO License : Valid

Total flying experience : 9888:50 hrs.

Experience on type : 2165:40 hrs.

Experience as PIC on type : 1736:10 hrs.

Total flying experience during 90 days : 61:40 hrs.

Total flying experience during 30 days : 02:50 hrs.

Total flying experience during 07 Days : nil

Total flying experience during 24 Hours : nil

1.5.2 Co-Pilot

Age : 42 years

License : CPL

Validity : Valid

Date of Medical Examination : 05/03/2014

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Med. Exam valid upto : 04/03/2015

FRTO License : Valid

Total flying experience : 2147:25 hrs.

Experience on type : 1383:05 hrs.

Experience as PIC on type : 398:15 hrs.

Total flying experience during 90 days : 55:30 hrs.

Total flying experience during 30 days : 2:50 hrs.

Total flying experience during 07 Days : 00 hrs

Total flying experience during 24 Hours : 00 hrs

1.6 Aircraft information

The aircraft was manufactured by M/s Raytheon Aircraft Company in 2005.

The aircraft is powered by 02 (two) PW PT6A-42 turboprop engines. These

engines have a Horsepower rating of 850 SHP with engine speed of 101.5%

N1 (38,100 RPM). The engines are fitted with Hartzell Inc Propellers model

No.HC-D4N-3A having 04 blades. The aircraft has a seating capacity of 10

persons including cockpit crew. The aircraft is certified for a single pilot

operation. There is only one door for normal entry/exit of the crew,

passengers and cargo. The aircraft has a total fuelling capacity of around

3636 lbs.

The aircraft was issued with Indian Certificate of Registration (C of R) no.

3295/2 in the name of the operator. Scrutiny of the Airframe and Engine log

books of the aircraft revealed that till the day of accident, the aircraft had done

2010.26 airframe hrs since new and 102.40 since the renewal of last C of A.

The engine had also logged 2010.26 hrs. since new. The last C of A was

done on 24.09.2013 and was valid till 28.07.2015. The aircraft was registered

under Normal category with subdivision as Passenger. The highest inspection

schedule on this aircraft is Phase IV (800 hrs) which was carried out on the

aircraft on 23.09.2013 at 1907.46 airframe hrs. The last inspection schedule

carried out was Phase I (200 hrs) and was carried out on the aircraft on

04.03.2014 at 2007.51 airframe hrs. The last flight operated by the aircraft

was on 14.03.2014 and the periodic ground run was carried out on

21.03.2014.

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The aircraft was issued with Certificate of Release to Service on 27.03.2014

after daily inspection. There was no snag on the aircraft after renewal of C of

A and the last snag reported was related to LH engine bleed air annunciator

on 22.08.2013. There was no snag reported on primary flight controls or

engine system.

All the mandatory modifications/SBs were found to be complied with. On the

day of the accident the Daily Inspection was carried on the aircraft by an

approved AME. As per the defect register maintained by the operator no snag

or defect was reported on the aircraft after 22.08.2013. Prior to that also

there was no snag relating to the aircraft controls.

FLIGHT CONTROLS - CONTROL SURFACES

The airplane is equipped with conventional ailerons and rudder. It utilizes a T-

tail horizontal stabilizer and elevators, mounted at the extreme top of the

vertical stabilizer.

OPERATING MECHANISMS

The airplane is equipped with conventional dual controls for the pilot and

copilot. The ailerons and elevators are operated by conventional control

wheels interconnected by a bar. The rudder pedals are interconnected by

linkage below the floor. These systems are connected to the control surfaces

through push-rod and cable-and-bellcrank systems. Rudder, elevator, and

aileron trim are adjustable with controls mounted on the center pedestal. A

position indicator for each of the trim tabs is integrated with its respective

control.

MANUAL ELEVATOR TRIM

Manual control of the elevator trim is accomplished with a trim control wheel

located on the left side of the pedestal. It is a conventional trim wheel which is

rolled forward for nose-down trim, and aft for nose-up trim.

ELECTRIC ELEVATOR TRIM

The electric elevator-trim system (installed in conjunction with the autopilot

system) is controlled by a dual-element thumb switch on each control wheel,

a trim-disconnect switch on each control wheel, and a PITCH TRIM circuit

breaker in the FLIGHT group on the right side circuit breaker panel. Both

elements of either dual- element thumb switch must be simultaneously moved

forward to achieve nose-down trim, aft for nose-up trim; when released, they

return to the center (OFF) position. Any activation of the trim system by the

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copilot's thumb switch can be overridden by the pilot's thumb switch. No one

switch element activates the system; only the simultaneous movement of a

pair of switch elements in the same direction activates the system.

A bi-level, push-button, momentary-on, trim-disconnect switch is located

inboard of the dual-element thumb switch on the outboard grip of each control

wheel. The electric elevator-trim system can be disconnected by depressing

either of these switches. Depressing either trim-disconnect switch to the first

of the two levels disconnects the autopilot and yaw damp systems;

depressing the switch to the second level disconnects the electric elevator-

trim system. The manual-trim control wheel can be used to change the trim

anytime the autopilot is off, whether or not the electric trim system is in the

operative mode.

RUDDER BOOST

A rudder boost system is provided to aid the pilot in maintaining directional

control in the event of an engine failure or a large variation of power between

the engines. Incorporated into the rudder cable system are two pneumatic

rudder-boosting servos that actuate the cables to provide rudder pressure to

help compensate for asymmetrical thrust.

During operation, a differential pressure valve accepts bleed air pressure from

each engine. When the pressure varies between the bleed air systems, the

shuttle in the differential pressure valve moves toward the low pressure side.

As the pressure difference reaches a preset tolerance, a switch on the low

pressure side closes, activating the rudder boost system. The system is

designed only to help compensate for asymmetrical thrust. Appropriate

trimming is to be accomplished by the pilot. Moving either or both of the bleed

air valve switches on the copilot's subpanel to the “INSTR & ENVIR OFF”

position will disengage the rudder boost system.

The system is controlled by a toggle switch, placarded RUDDER BOOST -

OFF, located on the pedestal below the rudder trim wheel. The switch is to be

turned ON before flight.

A preflight check of the system can be performed during the runup by

retarding the power on one engine to idle and advancing power on the op-

posite engine until the power difference between the engines is great enough

to close the switch that activates the rudder boost system. Movement of the

appropriate rudder pedal (left engine idling, right rudder pedal moves forward)

will be noted when the switch closes, indicating the system is functioning

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properly for low engine power on that side. Repeat the check with opposite

power settings to check for movement of the opposite rudder pedal.

YAW DAMP

A yaw damp system is part of the autopilot and is provided to aid the pilot in

maintaining directional control, and to increase ride comfort. The system may

be used at any altitude, and is required for flight above 17,000 feet. It should

be deactivated for takeoff and landing.

The yaw damper is automatically engaged anytime the autopilot is engaged,

except when rudder boost is activated. To disengage the yaw damper, slide

the YD/ AP DISC switch down on the FGP panel, press the YD push-button,

or press the DISC TRIM/AP YD switch on the pilot's or copilot's control wheel

to the first detent.

ANNUNCIATOR SYSTEM

The annunciator system consists of a warning annunciator panel (red)

centrally located in the glare shield, and a caution/advisory annunciator panel

(caution - amber; advisory - green) located on the center subpanel. Two red

MASTER WARNING flashers located in the glare shield (one in front of the

pilot and one in front of the copilot) are a part of the system, as are two amber

MASTER CAUTION flashers (located just inboard of the MASTER WARNING

flashers), and a PRESS TO TEST button located immediately to the right of

the warning annunciator panel.

The annunciators are of the word-readout type. Whenever a condition

monitored by the annunciator system occurs, a signal is generated and the

appropriate annunciator is illuminated.

If the fault requires the immediate attention and reaction of the pilot, the

appropriate red warning annunciator in the warning annunciator panel

illuminates and both MASTER WARNING flashers begin flashing. Any

illuminated lens in the warning annunciator panel will remain illuminated until

the fault is corrected. However, the MASTER WARNING flashers can be

extinguished by depressing the face of either MASTER WARNING flasher,

even if the fault is not corrected. In such a case, the MASTER WARNING

flashers will again be activated if an additional warning annunciator

illuminates. When a warning fault is corrected, the affected warning

annunciator will extinguish, but the MASTER WARNING flashers will continue

flashing until one of them is pressed.

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FLIGHT CONTROL ASSIST SYSTEMS - RUDDER BOOST SYSTEM

When the airplane is not equipped with an autopilot, the standard rudder

installation provides for rudder boosting and yaw damping functions.

Otherwise, these functions are provided by the autopilot. The systems

components are two pneumatic rudder servos, one pressure regulator and

two vented solenoid valves, all located aft of Fuselage Station (FS) 368.00,

an inline air filter mounted on the aft side of the aft pressure bulkhead and a

differential pressure switch located near the bleed air de-ice manifold. Each

servo is attached to the primary rudder cable by a cable and clamp. The

servo can be disconnected by removing one nut and on removing the servo

cable and clamp.

Each system is energized by a two position toggle switch on the pedestal

placarded “RUDDER BOOST ON OFF”. The systems are protected by a 5

amp circuit breaker on the right hand circuit breaker panel. The pressure

regulator is adjusted to 15 + 0.5 psi to boost the rudder against a failed

engine. When the air flow from either engine is reduced to the point that it

places a differential pressure across the pressure differential switch, it

actuates the appropriate solenoid valve allowing pressure from the de-ice

manifold to actuate the rudder servo.

FRICTION LOCK OF ENGINE CONTROLS

The Engine controls of SKA B200 are governed by two power and condition

levers of each engine, two prop lever for each propellers. All the controls are

equipped with friction pads controlled by a knob on the power quadrant of

pedestal below the knobs to control the friction on each control and its

movability. The friction locks are provided to prevent control creep back due

to cockpit vibration, springiness of control cables etc during all the phases of

flight.

Four friction locks are located, one for each power lever is equipped with a

friction brake, and one friction brake is available for both prop levers and

condition levers.

Clockwise movement of the knob increase the friction on the controls and

levers progressively become more resistant to movement.

As per the checklist for Before takeoff (run up) of POH Pg 4-20, engine

controls friction locks are required to be SET.

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1.7 Meteorological information

The following are the extracts from relevant METARs of the date of accident:

Time

(UTC)

Wind

Dir

Speed

(kts)

Visibility

(Km)

Clouds QNH Trend

0530 290 04 5 FEW030

BKN090

1015 NOSIG

0600 270 06 5 FEW030

BKN100

1014 NOSIG

0618 270 08 5 FEW030

BKN100

1014 NOSIG

0630 300 06 6 FEW030

BKN090

1014 NOSIG

1.8 Aids to navigation

In addition to VHF, HF, the aircraft is equipped with VOR / ILS Navigation

system. The navigation receiver is a fully integrated VOR / LOC, glide-slope,

Marker Beacon and ADF receiver. The ATC system available on the aircraft is

activated as soon as power is applied and Flight Management System is

operational.

The NAVAIDS available at Chandigarh Airport are as follows:

NDB CG 228 304039.400N 2720/ 1.51

NM to

Dmbl 11

1960/ 0.57

NM to

Dmbl 29

400 W

DVOR/DME CHG 116.5 0764817.860E 2910 /

1.66 NM

to Dmbl

11

2790 /

0.19 NM

to Dmbl

29

0200-

1400

UTC

ILS Rwy 11 CHD 110.3 GP : 30

PAPI Rwy 11/29 GP : 30 Left Side

CADF 1230 /0.91 NM from Dmbl 11

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1.9 Communications

There was two way communications between the aircraft and ATC.

1.10 Aerodrome information

Chandigarh Aerodrome is a Defence airfield with civil enclave owned by

Airports Authority of India. There is only one runway (11/29) of length 9000 ft

and width 150 ft. First 900 ft on either side of the runway is of concrete and

the rest of portion is bitumen. ILS/DME, VOR/DME is available for runway 11.

The communication frequency for tower and approach is 118.3 & 118.6

respectively.

1.11 Flight recorders

The aircraft was equipped with Fairchild CVR FA 2100 with Part No. 2100 –

1020-00 and Sl. No. 000333366. The CVR was replayed at the facilities of

Aircraft Engineering Directorate (AED) of DGCA. Neither there was any

requirement for fitment of FDR nor was any fitted on the aircraft.

1.12 Wreckage and impact information

Within 3-4 seconds of getting airborne the aircraft impacted ground in left

bank attitude. The initial impact was on pucca (tar road) and the left wing has

taken the first impact loads with lower surface metallic surface rubbing on

ground.

On the ground, there were marks of the propeller. The propeller blades of the

left engine had made cut marks on the ground and then skidding of the

aircraft. On the way both the propeller hub assemblies have got detached

from the main structure. The nose section also got separated from the aircraft

and was lying at a distance of 30‟ from the final position of aircraft.

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19

Rubbing marks observed on the ground are as in the drawing below:

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a-a : Mark of Propeller Striking the ground in running condition.

Dimensions (starting at 1 from right)

1-2 : 10” 8-9 : 17”

2-3 : 10” 9-10 : 17”

3-4 : 12” 10-11 : 22”

4-5 : 12” 11-12 : 22”

5-6 : 14” 12-13 : 26”

6-7 : 17” 13-14 : 31”

7-8 : 16”

1.13 Medical and pathological Information

Both the crew members had undergone pre flight medical examination and

were found fit. The breath analyser test was found negative. After the

accident also both the crew members were put for breath analyser test and

the test was found negative for both the crew members.

1.14 Fire

There was small fire to the grass due to spillage of hot oil and engine

exhaust.

1.15 Survival aspects

The accident was survivable.

1.16 Tests and research

The samples of the fuel and engine oil were taken after the accident and were

tested at the fuel and oil testing lab of Directorate of Civil Aviation at Delhi.

The fuel passed all the specified tests. The oil had also passed the

specifications tests regarding density, viscosity and flashpoint.

1.17 Organizational and management information

The operator had Non Scheduled Operators Permit (NSOP) and is an

Organisation based in Chandigarh operating with two aircraft under Private

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Operations for the use of State Government VIPs. The organisation was

structured under the management of the Accountable Manager.

The operating permit no. 03/2011 was valid till 22.12.2015. The Organisation

had approved CAME. The continuing airworthiness of the aircraft was

managed by CAMO approved organisation at New Delhi and Chandigarh. The

continuing airworthiness management functions were subcontracted to third

party. The maintenance was being carried out by another third party within the

requirements of CAR on the subject. The operations manual available with the

operator defines the duties and responsibilities of the cockpit member. In

addition to other responsibilities the pilot in command is responsible for

Use of the check list for every phase of flight.

Ensuring that no hazardous flight maneuver is executed during any

phase of the flight.

Affording every opportunity to the Co- Pilot to prepare himself for the

position of Pilot – in- command and explaining methods and procedures

being adopted.

The duties of co-pilot include

Render all material assistance to the Pilot –in-command

Shall carry out all duties pertaining to the operation of the flights as

directed by the Pilot-in-command.

Read out of the check list at the appropriate times and ensure that

same is being complied with.

1.18 Additional information

As per the “Before Take Off” checks of the pilot checklist, the operation of the

Yaw Damp has to be checked before take off (runup). Following steps are to

be followed in order to check the yaw damp:

1. Yaw Damp…………………………. ON (YAW) – illuminated

2. Rudder Pedals………………… check for added resistance

3. AP/Trim disconnect………………… depress to first level

[YAW DIS] – illuminated, flashing then extinguished

4. Repeat steps 1 through 3 for copilot‟s side.

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Similarly primary governor, over-speed governor and rudder boost is to be

checked as follows:

1. Rudder Boost ON

2. Prop Governor Test Switch Hold to test

3. Power levers (individually) Increase until prop is stabilized at 1800 to 1910 RPM

4. Prop Lever Retard to detent, then full forward

(to check primary governor)

5. Power Lever Continue to increase until rudder movement is noted (Observe ITT and Torque limits)

6. Power Lever Idle

7. Repeat steps 3 thru 6 on opposite engine

8. Prop Governor Test Switch Release

Further, as per the Section 3 of the “Emergency Procedures” of the Pilot

Operating Handbook of the aircraft, the rudder boost operation without a large

variation of power between the engines indicates a failure of the system. In

such a situation

1. Directional Control …………. ………..maintain using rudder pedals

2. Rudder Boost …………………………………………………OFF

As per para 6.15 of CAR - Section 3, Series C, Part X

“When operating VIP flights with fixed wing aircraft, the pilot-in-

command shall possess CPL or ATPL with at least 3000 hours including

2000 hours as PIC, 50 hours as PIC on type of aircraft to be flown and 50

hours of night flying experience. In addition, the pilot should have a

minimum of 30 hours as PIC experience in the last 6 months including five

hours on type in the last thirty days of the intended flight. In case 30 hrs.

recency during the last 6 months is not met with, then in last 30 days, a

satisfactory skill test (as required for licence renewal) shall be carried out

followed by 5 hrs. of PIC experience.”

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Further as per the Note 2 to para 6.17 of the CAR, VIP flight means a flight

having among its passengers any dignitaries (as per the list given there)

which include Governors of State.

1.19 Useful or effective investigation techniques

Nil

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2. ANALYSIS

2.1 Serviceability of the aircraft

The aircraft was having valid Certificate of Airworthiness, Certificate of

Registration and Flight Release. On the day of accident the AME carried out

the inspection. There was no snag and the aircraft was released for operation.

No item was released under MEL. The pilot had also accepted the aircraft and

the aircraft was moved under its own power from the Government Hangar for

embarkation of passengers from the bay indicating that all the controls

including rudder were operating in correct sense.

The engines were shut down. The crew has not reported any snag on the

aircraft systems or engines. No difficulty was reported by the crew regarding

operation of flight controls. The aircraft was again started and taken to runway

under its own power.

The crew members have reported that engines were generating full power.

The rudder boost was also serviceable before take-off. Till the beginning of

take off roll, the controls were functioning satisfactorily. The Commander had

reported that just before getting airborne some stiffness was found in rudder

control as is felt in yaw damper engagement. As per the co-pilot soon after

take-off roll the aircraft had started going to the left and continued to go to left

as the speed increased. He also mentioned that the aircraft had got airborne

from very close to the left edge of the runway.

As per the “Before Take Off” checks of the pilot checklist, the operation of the

Yaw Damp has to be checked before takeoff (runup) for both the Captain and

Co-pilot side. By putting yaw damp „ON‟, the rudder pedals are checked to see

for added resistance in operation.

As per Section 3 of the “Emergency Procedures” of the Pilot Operating

Handbook of the aircraft, the rudder boost operation without a large variation

of power between the engines indicates a failure of the system. In such a

situation the directional control is maintained by using rudder pedals after

putting the rudder Boost to „OFF‟.

The CVR was removed and tape transcript of the relevant portion was

prepared. It was observed that no check list was carried out by the flying crew.

This was agreed by the co-pilot also.

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The relevant extract of the CVR transcript for the accident flight is given below.

Relative Time (secs.)

by TEXT

00 P1 Oh yeh kya hua

00 P2 Kya

01 P1 ------

02 P1 Mera rudder lock ho gaya

03 P1 -------- Yaw damper

04 P2 Oh yaw damper

04 P1 Yaw damper off kar

05 P1 Kar off kar

09 P1 ------

10 P2 Ho gaya ab ho gaya

11 P1 Nahin hua yaar

14 P2 Ho gaya vo sir aapne green kar diya na dekho

17 P2 Rehne do

19 P1 Apne aap kaise engage ho gaya

22 P1 oye oye (aircraft crashes)

The CVR tape transcript of the take-off roll reveals that the commander of the

flight during take-off roll says “oh Rudder lock ho gaya”. The ATC prior to this

have given clearance to the aircraft to enter the runway and hold for clearance

to take-off. The aircraft has moved into the runway with the use of rudder and

the rudder movement was normal. As per the system and controls of the

aircraft the rudder pedal stiffness can exist only in case Yaw damper is „ON‟.

Immediate normal reaction of the commander was therefore that yaw damper

be put off. He has asked his Co-pilot to check & put off the yaw damper, which

was done by the Co-pilot. During take-off roll the rudder pedals are in the

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neutral position and the need of using rudder pedal arises only in case the

aircraft is not going straight. The emergency of Rudder pedal stiffness could

have been handled by taking corrective actions as mentioned in the report or

just by rejecting takeoff.

From the schematic of the control system, there was no reason that why the

yaw damp lever should go to „ON‟ during takeoff roll assuming that it has not

been put „ON‟ inadvertently by the crew. The matter was taken up with the

manufacture of the control system to find out if any information can be

retrieved from the Data Concentrator Unit or Flight Guidance Computer. These

units as such do not have any memory. The Manufacturer advised that

Maintenance Diagnostic Computer may be sent first to check if any data is

there. The matter was deliberated and it was opined that no useful information

can be retrieved from the units. It was advised to the Committee that as it is

not sure that we can get some relevant information and the other evidences on

record are capable to stand alone, the Committee may go ahead with the

investigation with the existing evidences.

Rudder Control Cable was checked in the cabin, under the floor board for any

defect, damage or unusual observations. Inspection was found satisfactory.

Rudder was commanded by Rudder Pedal and responding as desired

confirming the cable continuity. Rudder Boost Differential Pressure Switch was

checked for current status and found “on ground” with “engine not running”.

The same was also found working satisfactorily during operational check.

A118 (K4) Relay was checked for status on ground and found “on ground” and

responding to Bleed Air Switches.

Autopilot Disconnect Switch on Cockpit Control Column (both Pilot and

Copilot) was checked for serviceability and no abnormality was observed.

From the foregoing, it can be safely concluded that the aircraft was fully

serviceable prior to take-off and the aircraft serviceability has not contributed

to the cause of accident.

2.2 Crew qualification

Both the crew members were qualified to undertake the flight. They had valid

licences with appropriate endorsements. They had valid Medical certificates

for carrying out flying. Pre Flight Medical checks were also carried out prior to

flight and after the accident on both of them. The Breath analyser test was

negative for both of them.

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Honorable Governor of State is VIP as per Note 2 to para 6.17 of the CAR -

Section 3, Series C, Part X. The CAR requires that when operating VIP flights

with fixed wing aircraft, the pilot-in-command shall possess in addition to

other qualifications and experience, five hours of PIC experience in the last

thirty days of the intended flight. The Commander was not having 5 hours of

PIC experience in the last 30 days.

2.3 Weather

The sky was clear with few broken clouds at higher altitudes. The visibility

was 5 kms. without any significant changes anticipated. The visibility trend

was of improvement. The visibility and other weather conditions were

satisfactory for the conduct of flight and have not contributed to the accident.

2.4 Circumstances leading to the Accident

1. The Commander of the flight has stated that the yaw damper was not

engaged before the start of take-off roll and the Check-list was carried out

prior to start, after-start and before take-off. He has also said that sterile

cockpit environment was maintained during the flight. Whereas the co-pilot

stated that for positioning the aircraft at Bay D2 from the hangar he has

carried out the check-list but for the flight, it was not carried out. The CVR

was replayed which indicated that contrary to the statement of both the crew

members, no checklist was carried out at all. The CVR contained the

recording of last phase of earlier flight from Chandigarh to Delhi and full flight

from Delhi to Chandigarh. It was observed that no checklist has been carried

out during these flights.

2. As per the commander only after the speed of 80-85 knots was attained, it

pulled slightly to the left which was corrected by the help of rudders. After

which, a slight stiffness in the rudder was observed as in case of yaw-damper

engagement which when asked to the co-pilot was confirmed and observed to

be „OFF‟. This stiffness was only for 2-3 seconds and before the aircraft took-

off.

Whereas the co-pilot stated that soon after the take-off roll, the aircraft started

going to the left. As the speed increased, the aircraft continued to move to the

left. During lift-off, the aircraft was on the runway but towards the left of the

centre line. The Co-pilot was shown the video of the flight from take-off roll

onwards and the aircraft was found going to left and took off from close to the

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left edge of the runway. So during initiation of take-off roll itself, the aircraft

had started going to left.

3. The crew have stated that they have not heard any stall warning. CVR was

played and the Co-pilot identified the stall warning.

4. As per the crew, both the engines were generating full-power. The power-

lever(s) were guarded by the co-pilot and speed & power checked before

rotation. The take-off weight was 12315 Lbs and unstuck speed of 99 knots

with Flaps „UP‟. The stalling speed of aircraft in take-off configuration with the

weight of 12315 lbs. and flaps UP is within 78-80 knots. As per the co-pilot,

just after start of the take-off roll (after gaining speed of 40 knots) aircraft

started going to the left.

5. As per the commander there was no identifiable emergency to warrant and

abort take-off nor was the aircraft uncontrollable. ADF, VOR, ILS, DME, FMS

and GPS were functional. Whereas the co-pilot stated that Capt. repeatedly

kept saying that the aircraft is getting out of control and he is unable to

understand why aircraft is behaving like that. At that time, the co-pilot gave a

reject take off call (rehne do). As per the co-pilot, the commander unstuck

rapidly, probably, he might have thought that by taking-off, he will be in

position to control the problem.

6. As per the system and controls of the aircraft the rudder pedal stiffness can

exist only in case Yaw damper is „ON‟. Immediate normal reaction of the

commander was therefore that yaw damper be put off. The yaw damp can be

put off from the toggle switch available on the Front or by pressing the switch

available on the control stick to first level. In addition it can also be put off by

Yaw damper/auto pilot disconnect switch. From the CVR transcript

(conversation between the crew) it appears that the commander has probably

pressed the switch available on the control stick to put the yaw damper off

and simultaneously told the co-pilot to put the yaw damp off. The co-pilot has

pressed the toggle switch available on the front. During takeoff roll, the co-

pilot had meekly told the Commander to reject take off (rehne do). At this

crucial moment of take-off roll, there was confusion in the cockpit and there

was failure of CRM.

7. The aircraft had rotated and lifted off almost from the left edge of the runway

and in little left bank attitude. In view of the emergent situation in the cockpit,

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the Commander probably carried out rotation at a lower speed than VR. The

aircraft thereby stalled at a very low height and crashed.

In the hind sight, it is felt that the accident could have been avoided had the

crew

Put off the rudder boost switch.

Avoided simultaneous action of putting off the yaw damp by the

commander and co-pilot. Or

Rejecting the take-off.

3. CONCLUSIONS:

3.1 Findings:

1. The aircraft was having valid certificate of Registration and Certificate of

Airworthiness.

2. The Aircraft was issued Certificate of Release after carrying out daily

inspection on the day of accident and there was no snag reported.

3. All the mandatory modifications were complied with and there was no

deferred maintenance item or released under MEL.

4. No snag or defect was reported on the aircraft after 22.08.2013. prior to

that also, there was no snag relating to aircraft controls.

5. Both PIC and the Co-pilot were having valid licenses with appropriate

endorsements of Beechcraft King Air B-200.

6. PIC was not having 5 hrs. of PIC experience in the preceding 30 days.

7. Both the crew members held valid medical certificates as per the

requirement.

8. The crew had undergone pre-flight medical examination and nothing

abnormal was observed. The Breath Analyzer (BA) Test was negative.

Post-flight BA Test was also carried out and was negative.

9. On the day of accident, pre-flight briefing among the crew members was

carried out by using the documents prepared by a CPL holder (working as

Flight Dispatcher).

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10. The aircraft was parked in Haryana Government Hangar and was taxied

from there under its own power to Bay No. D-2 in front of ATC Building.

No abnormality was reported by the crew on the aircraft.

11. After boarding of the passengers, the aircraft was taxied out via Taxiway D

and lined up for take-off.

12. No check-list was carried out by the crew for the flight. The conversation

before take-off roll between the crew members was not relevant to the

flight.

13. The Pilot has not reported any abnormality of aircraft parameters.

14. During the take-off roll, the pilot observed stiffness in the rudder control

and the aircraft pulled slightly to the left.

15. On observing that the yaw damp was ON, both the crew members tried to

put off the yaw damp & in the process yaw damp first got off and then on.

16. There was failure of CRM and the emergency of stiff rudder was not

handled as per the checklist.

17. The crew failed to reject the takeoff.

3.2 Probable cause of the accident

The accident occurred due to stalling of left wing of the aircraft at a very low

height. The contributory factors were:

Failure on the part of the crew to effectively put off the yaw damp so as

to release the rudder stiffness as per the emergency checklist.

Checklist not being carried out by the crew members.

Not putting off the Rudder Boost.

Speeds call outs not made by co-pilot.

Not abandoning the take-off at lower speed (before V1).

Failure of CRM in the cockpit in case of emergency.

Early rotation and haste to take-off.

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